To save lives, midwives mix Mayan heritage with Western medicine

The fight to reduce maternal and infant deaths in Guatemala and Mexico doesn’t usually take place in fully staffed hospitals but in bare-boned rooms hours away.

Published 30 Mar 2022, 14:16 BST
Guatemala Childbirth
Clementa Eluvia Monterroso Romero dresses her recently born grandson under the watch of her four-year-old granddaughter, left, in the room where she assisted her daughter through birth. Monterroso Romero and her daughter are part of a group of traditional midwives in the community of La Victoria near Concepción Chiquirichapa, Guatemala.
Photograph by Janet Jarman, National Geographic

In a dimly lit green bedroom in Guatemala’s western highlands, the 66-year-old midwife chants the words like a prayer, mixing Spanish and her K’iche' Indigenous language as she cradles the woman giving birth on the ground before her.

“Breathe. Breathe, mija,” says Epifanía Elías. “You have to breathe. Be strong.”

Her patient, 25-year-old Leidy Chavez, writhes in pain, gripping the thick wool picnic blanket she has laid on the floor of her family’s home. None of Chavez’s family members are present, but Elías and her sister-in-law provide some comfort by gently stroking her hair.

In this tiny mountain village of stretching corn fields, where access to running water is scarce and basic healthcare services limited, pregnancies tend to be high-risk, according to the region’s health official. Indigenous midwives like Elías are the frontline soldiers in the battle to reduce maternal and infant death—not just in Guatemala but across other parts of Central America and southern Mexico.

Midwife Epifania Elías Gonzales examines Delfina Vicente López inside Vicente’s home on a remote hilltop not far from San Carlos Sija, Guatemala. During her 30-year career, Elías has helped hundreds of women in her predominantly K’iche' speaking Indigenous region, including advising women to go to area hospitals when pregnancy risks emerge.
Photograph by Janet Jarman, National Geographic

“They’re the women improving access to healthcare, because often women can’t go to places like health centres to give birth,” says Edgar Kestler, director of Guatemala’s Epidemiological Research Center in Sexual and Reproductive Health.

Guatemala has the highest maternal death rate in Latin America, according to a 2017 report from the World Bank (the most recent data available). In this country, 115 mothers die in childbirth, compared to the regional average of 87 per every 100,000 births. Infant mortality rates are even higher with two of every 100 children dying in birth.

“Such alarming figures can be attributed to the extremely low levels of formal prenatal and delivery care, especially in rural areas,” the World Bank report states. “Almost three-quarters of maternal deaths are among women of Indigenous ancestry.”

The fight to save mothers and newborns doesn’t usually take place in hospitals with well-staffed, well-equipped medical teams. It happens in bare-boned rooms like this one where Chavez is giving birth, hours from a hospital. As the sun sets over the distant mountains, the room gets quiet except for Elías softly whispering to the birthing mother, “ya está llegando”— here she comes. Seconds later, an eruption of cries comes from the newborn who gets swaddled in a sea blue blanket.

Midwives Gloria Cabrera Lorenzo, left, and Emelda López Sánchez assist Mayra Tamares Gómez Romero, 17, during her labor at a birth center run by the Association of Comadronas in the Mam Area (ACAM), as her husband and mother stand with her.
Photograph by Janet Jarman, National Geographic
In the tiny community of La Victoria, Guatemala, Lorenzo, standing foreground right, and López Sánchez, standing background left, explain how to use equipment from a new kit recently provided by ACAM. The event was part of an ongoing collaboration to recognize risks and signs of emergencies during pregnancy, birth, and post-birth.
Photograph by Janet Jarman, National Geographic

With mother and daughter now out of danger, Elías soon shifts her attention to other expectant mothers. She sometimes walks hours to reach patients, her simple medical bag slung over her shoulders in a red woven Mayan cloth.

The work done by midwives has become even more essential during the COVID-19 pandemic. Hospitals have struggled to stay afloat, and patients have been turned away from health facilities. Women like Elías fill in the cracks.

“We're doing what the health system doesn't,” she says. “We work more than the doctors, and we’re the ones helping women. Midnight. 1 a.m., 2 a.m., at any hour. When they call, ... you have to go to the patient.”

A boy rides his bike along a road in a remote area outside of Tuilcanabaj, Guatemala, where a team from ACAM regularly conducts a mobile health clinic for residents.
Photograph by Janet Jarman, National Geographic

Evolution of midwives

Here, in the remnants of the Mayan empire, a region spanning from southern Mexico to northern Central America, Indigenous women have been passing on the tradition for centuries. Known as parteras or comadronas, midwives were some of the region’s first healthcare providers.

The practice is believed to be a talent bestowed upon women, often handed down generation-to-generation. Mother to daughter, daughter to granddaughter.

As a young woman, Elías would watch her mother care for pregnant women, going house-to-house to do prenatal checkups, working with herbal medicines, delivering babies, and doing traditional steam baths, called “temazcal,” after the births.

Elías herself didn’t begin the work until she delivered her own baby, alone, on the floor of her kitchen. Her mother was off treating another patient when Elías, then 35, went into labour.

“I felt the baby was about to be born, so I woke my husband up and told him ‘Get up, the baby is coming.’ He told me ‘no, no, no. I don’t want to do it. Ay, I’m scared!’” she remembers.

“But I didn’t feel scared. I felt strong.”

She went on to become one of at least 22,000 traditional midwives working across Guatemala and 15,000 in Mexico, according to government figures. In Guatemala alone, comadronas deliver half of the country’s births.

Delfina Vicente López stands at the center of a private ceremony led by a priest inside her home in Aldea Nuevo San Antonio, Guatemala. The priest, moved from traditional Catholic prayers to a trance-like ritual meant to rid the home of negative energy and prepare for the birth of her son.
Photograph by Janet Jarman, National Geographic

Over three decades, Eiías has become the most active and trusted midwife in her area, taking daily treks to see patients.

“Those women (patients) fall under the care of the comadrona, who go to their homes and shorten the massive distances between these communities (and healthcare),” Kestler says.

Midwife Epifania Elías Gonzales has maintained consistent training over her career and is well aware of alarm signals that require birthing mothers go to the hospital for delivery.
Photograph by Janet Jarman, National Geographic

Maternal and infant mortality are preventable crises defined by global health inequalities.

Health providers across the globe have been able to slash death rates among women and infants over the past two decades, especially in higher-income nations, says Aboubacar Kampo, health program director for UNICEF. Midwives, says Kampo, are crucial to that progress.

“We’ve halved the number of (global maternal and infant) deaths, and that’s definitely a success,” he says. “I don’t think the global community has wasted its time.”

Yet the danger is still high in parts of Latin America, sub-Saharan Africa, and Southeast Asia.

The toll of COVID-19

In the broader Mayan region, Indigenous and rural women are more vulnerable to high-risk pregnancies. In Guatemala, they’re twice as likely to die during birth than the average woman, United Nations data shows. Those women are also fighting a range of uphill battles, including a growing hunger crisis.

In this farming town of Nuevo San Antonio, the closest thing residents have to a health centre is a small building, perpetually understaffed with broken medical equipment, where the first thing nurses ask is: “Is your child malnourished?”

Juana Girón Santis works through her labor pains next to her mother, Lucia Santis Mendez, while traditional midwife and Nich Ixim member Lucia Girón Pérez helps at her home in Tzajalchén, a small community in Chiapas, Mexico.
Photograph by Photograph b Janet Jarmin
Lucia Girón Pérez documents a birth, minutes after she delivered a baby inside the birthing room at her home. She records all births with babies’ footprints in her own registry catalog and on an additional official birth registry document from the midwife advocacy group Nich Ixim.
In this region of Chiapas, many mothers and babies Gíron treats are undernourished, she said. This baby weighed only four and a half pounds at birth. Girón lost her first child during childbirth, and the tragedy inspired her to become a midwife to help the women of her community avoid the same fate.
As the COVID-19 pandemic spread throughout the region, Indigenous women began to fear hospital safety even more. As a result, Girón’s workload spiked, attending 346 births in 2020, 403 in 2021, and more than 90 so far this year.

Lack of state presence in such zones has spurred accusations by experts, doctors, women, and midwives, who say that regional governments have failed women in rural areas.

While Guatemala’s Health Ministry declined to comment on criticisms, Ana Luz de León Barrios, of the country’s National Program of Reproductive Health, attributed the lack of health services to logistics.

“We’re a country … that has many problems with its infrastructure, with very far-off communities, so it impedes health services from reaching many people,” León Barrios says.

Christian Ixmay Perez takes traditional midwife Epifania Elías Gonzales to his home in Aldea Nuevo San Antonio, Guatemala so she could tend to his mother who had gone into labor earlier in the day.
Photograph by Janet Jarman, National Geographic

Without advanced medical care or the resources to pay a private clinic, women seek out midwives. But comandronas like Elías often earn little more than 400 quetzales (£40) for weeks of work that includes prenatal care through childbirth. Because of it, midwives, too, often lack basic resources including stethoscopes, oximeters, and ultrasound machines, essential tools in detecting complications early on.

Over the past two years, access to healthcare has diminished, just as endemic fear of mistreatment or exposure to the coronavirus festered. For many midwives work has more than doubled.

“Women don’t want to go to the hospital, even if the pregnancy complicates, because they can get infected [with COVID], so they think it's better to do it at home,” Elías says. “They say: ‘If I die, I'm going to die here, not in the hospital.’”

That was the choice made by Elías’s patient, Chavez, who smiled as she cuddled her newborn daughter under a pile of blankets.

Clementa Eluvia Monterroso Romero listens to her granddaughter while working with her family to prepare tamales in La Victoria, Guatemala. She, along with her sister, are midwives.
Photograph by Janet Jarman, National Geographic
Monterrosa Romero, 70, listens to an explanation of how to use the oximeter included in the new kits provided to her and her colleagues by ACAM. The event was part of an ongoing collaboration designed to share knowledge about risks and emergencies to look out for during pregnancy.
Photograph by Janet Jarman, National Geographic

This pregnancy had been marked by difficulties. With the region’s economy still ravaged by COVID-19, Chavez has struggled to put food on the table and she could not afford to buy prenatal pills before the birth. She managed to pay for an ultrasound at a private clinic about 30 minutes away, but it cost her two days of work in the cornfields.

To make ends meet, her husband migrated to the United States to work, leaving her alone, just a year after a previous pregnancy ended in miscarriage. She worried the same would happen with her recent pregnancy.

Elías Gonzales, left, visits one of her patients, Delfina Vicente López, at her home in Aldea Nuevo San Antonio, Guatemala days before her due date.
Photograph by Janet Jarman, National Geographic

“I was scared that I would lose my baby,” she said. “But thank God, everything was fine.”

While aid providers like UNICEF say it’s still difficult to pinpoint exactly how much progress on infant and maternal mortality has been lost during the pandemic in Guatemala and elsewhere, Kampo says the backslide will be felt for decades.

 “We’ve lost (progress). Now, is it 10 years, or 20 years? It’s difficult to say because we haven’t seen the full fallout of COVID-19,” Kampo says. “But it’ll take us a long time to recover, especially in poorer countries.”

A cultural chasm

The fear of a potential uptick in infant and mortality rates, coupled with patients seeking a higher level of medical care as a last resort has resurfaced old tensions between health officials and midwives.

Sisters Josefa Monterroso Romero, center, and Clementa Eluvia Monterroso Romero, wait inside the health clinic in La Victoria, where they were called in to show documents, including proof of COVID-19 vaccination and identification cards. The two midwives attend monthly meetings at the clinic.
Photograph by Janet Jarman, National Geographic

Both fight for the same thing—reducing maternal and infant deaths—but simultaneously exist on two sides of a chasm that has divided the region for decades.

Midwives accuse medical staff of discriminating against them, mistreating their patients, and blocking them from entering medical facilities. Health officials, meanwhile, are quick to note the important role midwives play across the region, but some also blame the comadronas for maternal deaths. They accuse comadronas of bringing birthing mothers to the hospitals after it's too late.

“You feel frustrated because you know you could’ve done more, but in the end, it just wasn't possible,” Alvaro Recinos, who works at a hospital in Guatemala’s second biggest city, says of the patients he’s lost.

Some health authorities also say many midwives are not qualified to deliver births and accuse some of using unauthorised drugs on patients. While there is no hard evidence to back those claims, physicians say they often see patients come to the hospital in grave condition with symptoms from the drug, oxytocin, used to induce labor.

Frenzied hospital care

At the hospital in Quetzaltenango, Recinos rushes with a pack of other doctors and nurses to wheel in a young woman who is in labour. The hospital is the only source of higher-level care in western Guatemala, and women sometimes travel half a day to get here.

While the workload for midwives like Elías has skyrocketed, the number of expectant mothers doctors treat has decreased. But when women do arrive to the hospital during childbirth, they often come on their deathbeds, Recinos says.

Gynecologist Diego Vicente (wearing a white hat) and colleagues finish performing an emergency Cesarean on Doyli Aylin Hernández at a hospital in Quetzaltenango, Guatemala.
Medical personnel extract the baby of Doyli Aylin Hernández as they performed an emergency Cesarean. The hospital in Quetzaltenango is one of the three largest in Guatemala, and among just a few equipped to handle high-risk complicated births and obstetric emergencies.

On this day, the hospital staff is frantically tending to a patient with a heart condition that went undiagnosed because she had no health centre in her rural community. Now, she’s giving birth during cardiac arrest. 

Nurses line up sets of towels and scissors, preparing for the Cesarean surgery as if they were going to war. Recinos, wearing a Garfield scrub cap and a N95 mask wrapped around his face, snaps on a pair of gloves.

Recinos tells the woman—half conscious, scared, and alone—“you’re going to feel a little cold,” as a group of doctors operate. After two hours in a tense surgical room, the stress slowly melts away as the patient's vital signs stabilise with the steady “beep, beep, beep” of the heart monitor.

“If she had decided to have her birth with a comadrona, she would have died,” Recinos says.

Yet it’s those very midwives who often convince women to seek healthcare in hospitals in high-risk situations like this one.

‘Keeping this tradition alive’

In the high hills above Quetzaltenango’s hospital, Emelda López Sánchez stands in the single room of an adobe home in the heart of Concepción Chiquirichapa, a tiny 17,000-person town marked by dirt roads and potato farms.

The 40-year-old comadrona carefully wraps a blood pressure monitor around one of the woman’s arms as a dozen of midwives around her watch intently. The midwives peer over as López Sánchez explains in her native language, Mam, how to take a blood pressure reading.

Traditional midwife Lucia Girón Pérez, left, greets her neighbor, Elena Gión Guzman, while walking home from seeing a pregnant woman under her care in Tzajalchen, a small community in the municipality of Tenejapa, Chiapas, Mexico. Both women carry medicinal plants used in the region.
Photograph by Janet Jarman, National Geographic

She leads the Association of Comadronas in the Mam Area (ACAM), a collective of 71 midwives surrounding the small town of Concepcion Chiquirichapa. The collective is just one of hundreds of grassroots groups across the region working to train midwives based in far-off communities.

Midwives in the Mayan region have fought a decades-long battle to be recognised by their governments and to bridge the divide with the public health system.

Guatemala and Mexico’s governments have launched programs to help train midwives, and provide some resources. But critics say those efforts have fallen flat.

“Traditional midwives here are incredibly important, and will be incredibly important in the next 50 years. But not because there’s a health policy recognizing that,” Kestler says. “Rather, it’s the exact opposite. The health system is so fragmented, with such little focus on primary care, and that’s where comadronas get their importance.”

ACAM travels by bus out to remote communities to provide ultrasounds and prenatal kits. The organisation also constructed a birthing clinic, staffed with a handful of medically trained traditional midwives and a doctor who assists in more complex cases.

Clementa Eluvia Monterroso Romero bathes her newborn grandson Breiner Eduardo Vicente Vasquez inside a temazcal steam bath in her backyard, a tradition that is also done with the new mother to help her relax after a strenuous birth.
Photograph by Janet Jarman, National Geographic

“While the government doesn’t recognise us, we’re at least doing something important in our community,” she said. “We’ve mixed traditional medicine with Western medicine, and it’s helped a lot.”

In Mexico, such movements have gained even more traction, becoming a voice pushing for international recognition. In southern Chiapas, the grassroots movement Nich Ixim was created in 2014 to pressure authorities into recognising midwives’ work.

“We’ve learned it’s much better to be united than all alone,” says Ofelia Pérez, a leader of the movement.

For Pérez and López Sánchez, the work also serves another purpose: to pass on a dying tradition.

ACAM was formed 17 years ago to train a new generation, the children of current comadronas. But today, leaders say younger women have turned away from the practice, causing scarcity at a time when UNICEF’s Kampo highlights a need for more midwives.

It’s an existential threat, not just for midwives, but to the very women they serve, says López Sánchez.

“If comadronas were to go extinct, the consequences would be the deaths of many women,” she says. “And hospitals could collapse from the number of patients.”

Over the years, the midwives of ACAM have served women in the predominantly Indigenous areas by providing safe and culturally appropriate maternal health services. Here, midwives and sisters Clementa Eluvia Monterroso Romero, 69, left, and Josefa Monterroso Romero, 70, walk down the street of the tiny community La Victoria, Guatemala.
Photograph by Janet Jarman, National Geographic

But in the pandemic, their small building has gained increasing importance in their small community, bringing new hope that their work won’t die out.

“It's about preserving the culture. Keeping this tradition alive,” she says, wrapping her hand around the fabric of her deep green and blue Mayan skirt as her team drives down a rugged roadway, returning from a training. “We have to continue passing it on to the next generation.”

María Elena Pérez Jiménez holds her one-day-old son after delivering him at her home with assistance by Guadalupe Guzman Cruz, her mother-in-law and a midwife.
Photograph by Janet Jarmin
Megan Janetsky is a Colombia-based journalist covering human rights, migration, gender issues, and politics across Latin America.

Janet Jarman is a documentary photographer and filmmaker based in Mexico City. Follow her on Instagram.
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